DISCLAIMER: The cases / examples on this blog have been anonymised to maintain confidentiality of patients. Cases have been acquired from various international hospitals and through other medical colleagues with the intention to teach through case examples.

Wednesday, 17 August 2011

It's been a while since I last wrote on the blog. Many of you probably thought I had forgotten about it. Quite the contrary, but I have been very busy with other things though. I will continue to write on here from time to time but with no guarantees when.....sorry :-)

I wanted to talk about the use of evidence based medical practice in every day medicine.

Many physicians talk about evidence based medicine and it's importance in modern day medicine, but when it comes to actual patient care, some do not apply it stating variously that "in A country we do x,y,z treatments instead". That is not to say that the local treatment(s) is/are wrong, but without evidence to support it's use compared to well established medicines or procedures that do have a body of evidence, how can the local treatment(s) surmount evidence based treatment?

In many instances a senior has decided the treatment based on what they were taught combined with experience based practice. Hence, "if it ain't broken then why try and fix it?" Well, the use of EBM provides the best current established methods that can support the physician to provide medical therapy in the best possible manner. Of course, such treatment may be very different from local established therapy but that does not mean it should not be utilized.

Many physicians wish to remain in a comfort zone of practice of not using a new treatment method because of fear of it causing a problem, inexperience in the use of drugs or procedures, and fear that they will not get support from their fellow colleagues who may only be practicing "eminence based medicine". The fear of the unknown is a strong emotion to stop us moving forwards as physicians to provide the best possible treatment.

For example, it is said that amiodarone use in Japan is minimal for the "fear" of the side effects, which in the acute phase of use are actually minimal and in the long term can of course cause problems, but on minimal maintenance dose, such side effects can also be limited. The fear of never having used it, for example in atrial fibrillation, instead translates into the use of class I cardiac drugs that have inherent dangerous side effects such as proarrhythmia induction or class IV calcium channel blockers that can cause worsening systolic failure in patients with existing ventricular dysfunction. These decisions may not be optimal, but it is fear of the unknown that causes such paralysis in medical decision making leading to the use of treatments that may be inferior to those used in best practise.

It is also said that in episodes of benign paroxysmal positional vertigo, patients in Japan are given intravenous bicarbonate. When challenged about the evidence for the use of such treatment, some doctors can be vague and use the standard dogma of "this is standard therapy here" without being able to provide firm evidence for the benefit of such therapy. Evidence based texts e.g. UpToDate, can provide the current standard of therapy with references that one can rely on to make clinical decisions rather than resorting to old therapies that have not been critically tested in large trials.

The fear of providing pain relief to patients is another example leading to paralysis of clinical decisions. Severe pain may not be amenable to the usual acetaminophen or NSAIDs. Sometimes the only treatment that can lead to adequate pain control can be opioids/opiates. There is again a strong fear factor that patients will become addicts or that they will stop breathing. This can sometimes translate into patients without cancer being refused adequate pain control, which may be severe, or patients with cancer being underdosed, because of physician fear.

The laws controlling the use of narcotics in Japan are very strick having been produced over 50 years ago and which need a significant overhaul for treatment of modern day patients. It is said that only patients with cancer can have opiates and even then, some physicians need a special license to prescribe it. The fact that patients in severe pain do not stop breathing with opiates is a testament that when used appropriately, they are safe. Moreover, use in the short term e.g. acute myocardial infaction and postoperatively, there is no induction of addiction. The fact that the opiate use in Japan is 1/7 that of the UK despite it having comparatively double the population, reflects the aversion of it's use in the medical community generally.

The use of EBM can help to support the physician to make difficult decisions when their experience base runs out. A physician should always recognize their limitations. If they are unable to answer the question themselves, they can ask for a specialist opinion or they can go to the books. However, the books are only as good as the time of when they were written and usually, by the time they go to print they are already out of date! Therefore, utilizing an EBM database that is updated regularly must be the best current way to answer difficult clinical questions.

One should also bear in mind that EBM texts are not just there to help with therapy. They are produced to aid the physician to consider differential diagnosis to try and prevent premature closure of diagnosis. In the early stage of an illness with few symptoms and clinical signs it can be difficult to be specific about a diagnosis. Such texts can help guide the physician about the natural history of disease and atypical manifestations and presentations. This can be very valuable as no physician can hold mountains of information in their minds ad infinitum. With the ever changing world of medicine and epidemiology of diseases over time, an updated EBM text can be a very helpful assistant.

It should never be an embarrassment to not remember something, but it is an embarrassment and sometimes negligent, if information can be checked but it is not done so because of pride of supposedly "knowing everything I need to know". From my own perspective, the more I read to keep updated, the more I realize that I know even less. I end up with more questions that when I started.

I shall no doubt be writing more on this in the future.

Essentially, there is no excuse to avoid the use of EBM at the bedside to assist in patient care. EBM can answer many of the clinical questions that come up everyday on the ward. The fear of the unknown and uncertainty is something physicians must deal with everyday. There is no escaping it by ordering more and more tests, and which "play for time", and which are unlikely to answer the questions.

As a word of warning, the use of EBM in a patient with for example, X disease, should lead to the use of that same evidence and application of it for all future patients with X disease (but by also checking to make sure the EBM recommendations are still the same or have been updated) rather than it being an isolated case or an "experimentation with EBM".

We as physicians need to keep as knowledgable as possible about the changes in medicine and by reading thoroughly we can increase our comfort zone of knowledge by applying this to patient care at the bedside rather than being fearful of the "unknown" and "personally untested". We should embrace EBM to provide the best possible patient care.

Reading EBM is good but applying it in reality is the only way to improve patient care otherwise we have a situation of "one hand clapping". Without two hands i.e. Reading and applying what was read, we will make no clapping noise and as a result, patient care will remain unchanged.